Workers at Maryland's maximum-security psychiatric hospital in Jessup, where two patients were slain recently, are calling on the state to address what they describe as problems in treatment and a pervasive climate of fear.

In the letter to state officials, workers said some patients at Clifton T. Perkins Hospital Center "are under-medicated and others are over-medicated." The workers said treatment teams do not get input from the direct-care staff, so the teams "are often out-of-touch and therefore make dangerous clinical decisions regarding these very dangerous clients."

The union representing many staffers said the fear — which some patients also complain about — even extends to doctors. "Staff have seen doctors showing serious fear of clients. … Doctors need to be trained to not show their fear of clients to either staff or clients," said the letter, which called for improvements in staffing and other areas.

Statistics provided by the state illustrate the dangers of working or living at Perkins. There were 267 assaults by patients on other patients or staff in fiscal 2011, up from 228 in 2010 and 225 in 2009, according to the state, although fewer than a dozen a year resulted in hospitalization. About 150 of the assaults each year involved only patients.

Meanwhile, five staff members were fired for using excessive force on patients during the same three-year period. And three staffers were criminally charged with assault after a 2010 incident at the hospital.

"Perkins is a dangerous place to work because you have people there who have been committed there because they have committed violent acts," said Patrick Moran, director of American Federation of State, County and Municipal Employees Maryland. "It is our opinion that the state should do everything they can to ratchet down people's concerns at every angle."

State officials say there is a delicate balancing act in maintaining a secure environment at Perkins, which has about 250 patients, while helping such a challenging group recover.

The new chief executive recruited to Perkins last week from Spring Grove Hospital Center in Catonsville, another state psychiatric facility, said he is addressing the climate of fear.

"I'm not sure it's possible to erase fear completely, but that would be the goal," said Dr. David S. Helsel, who is scheduled to take over as Perkins' CEO next week. "With the nature of the patient population, everyone has to exercise caution and there will be some degree of people looking over their shoulder. The culture of fear can't be erased until everyone feels safe."

The complaints regarding Perkins raise questions about whether much has improved since El Soundani El-Wahhabi, a known sex offender, was charged with murdering Susan Sachs at the hospital in 2010. A review of that incident found workers sleeping on the job and other shortcomings. A state panel recommended keeping the halls well lit, walking rounds every 30 minutes, and ensuring that an alarm sounded when a patient's bedroom door opened.

The recent spate of violence began Oct. 21, when David Rico-Noyola was found dead; police charged roommate Vitali Davydov with murder. Six days later, Rogelio Mondragon was found dead in his room on the same ward; patient Andre Mayo was charged with his murder.

It's not clear how Mayo was able to enter Mondragon's room on the maximum-security ward, where there is one staff member for every three or four patients per shift.

Even before the two October slayings, fear had permeated Perkins, according to advocates, employees and patients. Patients not only fear one another, but some say they are scared of the staffers who control their privileges. Staff members, meanwhile, are on constant guard as they monitor patients whose mental illness has driven many of them to kill or commit other violent crimes.

Laura Cain of the Maryland Disability Law Center, an advocacy group, said, "The culture really needs to change and the hospital leadership needs to find out ways to reduce that level of fear. Everybody is afraid."

Cain said the climate at Perkins remains ripe for problems and accused the hospital of not doing enough to protect patients. A near-lockdown and lack of outside grief counseling after the recent killings only intensified the climate of fear, she said.

Some who have been committed to Perkins say they've developed strategies for staying safe. One watches television to remain awake through the dark and less-monitored night hours; another avoids eye contact with other patients.

"It takes two or three minutes to kill someone," said Brandon Hart, who was sent to Perkins this year after being charged with assault. "In prison, you're not dealing with a mental person. Here, you're dealing with a criminal and a mental person. Blink the wrong way and he can snap."

There are many reasons for the feveredatmosphere, patients and advocates say: inconsistent leadership at Perkins, which just named its third new head in a year; a lack of therapy for some patients; and shared rooms even among those with the most violent histories. Patients say staffers are inattentive, while union leaders say workers get little support from the top and are trained with antiquated methods.

The workers' letter to state officials listed recommendations for improving safety that included ensuring patients are properly medicated and increasing evening activities for patients to prevent problems born of boredom. They also wanted re-evaluations of roommate pairings, more staff training and fewer employees working 16-hour days.

In addition to the five Perkins workers who were fired since 2009 for using excessive force, court documents show at least three workers have been criminally charged in the last year for violence against patients.

Patient Lori Shilling accused four staff members of abusing her near the nurse's station on the night of June 9, 2010, when she tried to go to the quiet room because she couldn't sleep. In court documents, Shilling said the women tried to drag her back to her room. One stamped on her foot when Shilling tried to resist and the others dragged her by the hair, according to the documents. The incident was caught on surveillance video.

Three of the staff members were charged with second-degree assault. Attorneys for the staff said in Howard County District Court documents that Shilling's aggressive and belligerent behavior prevented them from using "approved holds" to get her back to her room. They also accused Shilling of "pill-seeking" — trying to get unapproved medication.

One worker pleaded guilty but can have her record expunged in a year. Charges were dropped against another worker, and the third is awaiting trial.

Pledges of improved security have come from top state officials, inluding Dr. Brian Hepburn, director of the Mental Hygiene Administration.

He said every system is being reviewed — from staff levels and training to oversight. Also, patients are being reassessed for their propensity for violence and for their treatment needs. That may result in some patients changing rooms or wards.

"After two incidents, nothing is being taken for granted," said Hepburn, adding he understood that staff and patients are afraid. "I think that's appropriate. When you're in a situation where there have been two murders, I'd be surprised if the predominant mood was not fear. …The goal now as much as possible is to provide security."

Donna Lewis, a mother of a patient who did not want to be identified for fear of retribution, fears her son is not safe at Perkins.

Lewis, who lives in North Carolina, said her son is not receiving medications or therapy, though he seems to be doing well without it. She lamented that Perkins was not equipped for him to earn his high school equivalency degree. Her son had been charged with assault.

Now that other freedoms are being curtailed in the name of safety, she worries the environment will become more tense — and dangerous.

"I'm so sad for the families of the other patients who were killed," she said. "It's a horrible situation there. I'm not sure my son is getting anything positive at Perkins right now."